Characterization of Antibiotic Resistance in Select Tertiary Hospitals in Uganda: An Evaluation of 2020 to 2023 Routine Surveillance Data.

Antimicrobial resistance (AMR) is a public health concern in Uganda. We sought to conduct an extended profiling of AMR burden at selected Ugandan tertiary hospitals. We analyzed routine surveillance data collected between October 2020 and March 2023 from 10 tertiary hospitals. The analysis was stratified according to the hospital unit, age, gender, specimen type, and time. Up to 2754 isolates were recovered, primarily from pus: 1443 (52.4%); urine: 1035 (37.6%); and blood: 245 (8.9%). Most pathogens were Staphylococcus aureus, 1020 (37%), Escherichia coli, 808 (29.3%), and Klebsiella spp., 200 (7.3%). Only 28% of Escherichia coli and 42% of the other Enterobacterales were susceptible to ceftriaxone, while only 44% of Staphylococcus aureus were susceptible to methicillin (56% were MRSA). Enterococcus spp. susceptibility to vancomycin was 72%. The 5-24-year-old had 8% lower ampicillin susceptibility than the >65-year-old, while the 25-44-year-old had 8% lower ciprofloxacin susceptibility than the >65-year-old. The 0-4-year-old had 8% higher ciprofloxacin susceptibility. Only erythromycin susceptibility varied by sex, being higher in males. Escherichia coli ciprofloxacin susceptibility in blood (57%) was higher than in urine (39%) or pus (28%), as was ceftriaxone susceptibility in blood (44%) versus urine (34%) or pus (14%). Klebsiella spp. susceptibility to ciprofloxacin and meropenem decreased by 55% and 47%, respectively, during the evaluation period. During the same period, Escherichia coli ciprofloxacin susceptibility decreased by 40%, while Staphylococcus aureus gentamicin susceptibility decreased by 37%. Resistance was high across the Access and Watch antibiotic categories, varying with time, age, sex, specimen type, and hospital unit. Effective antimicrobial stewardship targeted at the critical AMR drivers is urgently needed.

A large outbreak of typhoid fever associated with a high rate of intestinal perforation in Kasese District, Uganda, 2008-2009.

BACKGROUND: Salmonella enterica serovar Typhi (Salmonella Typhi) causes an estimated 22 million typhoid fever cases and 216 000 deaths annually worldwide. In Africa, the lack of laboratory diagnostic capacity limits the ability to recognize endemic typhoid fever and to detect outbreaks. We report a large laboratory-confirmed outbreak of typhoid fever in Uganda with a high proportion of intestinal perforations (IPs). METHODS: A suspected case of typhoid fever was defined as fever and abdominal pain in a person with either vomiting, diarrhea, constipation, headache, weakness, arthralgia, poor response to antimalarial medications, or IP. From March 4, 2009 to April 17, 2009, specimens for blood and stool cultures and serology were collected from suspected cases. Antimicrobial susceptibility testing and pulsed-field gel electrophoresis (PFGE) were performed on Salmonella Typhi isolates. Surgical specimens from patients with IP were examined. A community survey was conducted to characterize the extent of the outbreak. RESULTS: From December 27, 2007 to July 30, 2009, 577 cases, 289 hospitalizations, 249 IPs, and 47 deaths from typhoid fever occurred; Salmonella Typhi was isolated from 27 (33%) of 81 patients. Isolates demonstrated multiple PFGE patterns and uniform susceptibility to ciprofloxacin. Surgical specimens from 30 patients were consistent with typhoid fever. Estimated typhoid fever incidence in the community survey was 8092 cases per 100 000 persons. CONCLUSIONS: This typhoid fever outbreak was detected because of an elevated number of IPs. Underreporting of milder illnesses and delayed and inadequate antimicrobial treatment contributed to the high perforation rate. Enhancing laboratory capacity for detection is critical to improving typhoid fever control.

Suspected outbreak of cutaneous anthrax in Kasese district, the investigation and response, April to May 2007.

BACKGROUND: A report of suspected anthrax was submitted by the Kasese District Health Office to the Epidemiology Surveillance Division of Ministry of Health. A joint team comprising officers from MOH, IPH and MPH officers proceeded to the district to investigate the reported threat of anthrax. The investigations were conducted in Bwera HSD, Bukonjo West County, in communities bordering Queen Elizabeth National Park. OBJECTIVES: The main objectives of the study were to verify the existence of anthrax and assess the risk factors for the suspected outbreak of anthrax in Kasese district. METHODS: The methods involved discussion with the DHT members; reviewing the surveillance data and hospital records, and reorienting the case definitions to the specific type of anthrax. In addition tracing the reported cases in the community in order to establish exposure to the risk factors and sensitize the community. RESULTS: Cutaneous anthrax was clinically diagnosed as the cause of the reported anthrax, both from the medical records and observation of cases found during the investigation. The index case was a 44 year old male, from Hurukungu village, Kyempara parish, a household with one wife and 4 children. This case skinned a goat that had died under mysterious circumstances and the meat was eaten with family members. Two other cases were members of the same family and the fourth case was from the same community and bought meat from the index case. All the four cases presented with a history of blister like lesions that eventually ulcerated with swelling of surrounding skin in different parts of the body. There were no other systemic symptoms reported in all the cases. All the suspected cases received antibiotics to which anthrax is sensitive. There were no laboratory investigations done by the time of the investigations since many of the cases identified were already on treatment and recovering from the infection, therefore no samples were taken from them. Review of records revealed that reporting of anthrax has continued since the year 2005 with cases ranging from I to 4 from villages that shares a common boarder with Queen Elizabeth National Game Park. This particular outbreak was associated with eating of meat from a goat that had died of unknown cause. The health workers from the health units where cases were reported were found to have the basic knowledge and skills to suspect anthrax. However, they had no guidelines to help them identify cases of anthrax accurately. The available Standard Case Definition (SCD) booklets, IDSR Technical Guidelines, and laboratory SOPs have no information on anthrax. No samples have ever been removed from suspected cases for laboratory investigation. The health units have the appropriate antibiotics for treatment of suspected case. The Local Council Chairpersons, Veterinary extension workers, and the health educators have sensitized the community in the past against eating dead animals and that they should notify the authorities, and bury all dead animals immediately. However this hasn't yet been done for the current outbreak. CONCLUSION: The outbreak of anthrax in Bwera sub-county followed eating of meat from a goat which had died from unknown causes. Suspected cases have not been confirmed by laboratory but treated empirically with antibiotics. All new cases of suspected anthrax that report at the lower health units without laboratory facilities should be referred to hospital for investigation to confirm the diagnosis. There is need to include guidelines on anthrax in the SCD Booklets, laboratory SOPs and IDSR technical guidelines. Resensitization of the affected communities about the prevention of anthrax should be done immediately.